Background: Throughout rural and urban communities in the United States, as well as in many places globally, chronic disease rates are high and increasing. Previous evidence suggests that residential environments and their designs play a role in shaping health behaviors and outcomes. Combining land use development with urban agricultural practices to create agriculturally-integrated neighborhoods (‘agrihoods’) has potential for improving the built, natural, and food environments while building community. However, the research on agrihoods is limited, and no structured reviews to date have synthesized the literature pertaining to agrihood impacts on community health. We begin filling this gap by providing a narrative review of the published and grey literature exploring opportunities and challenges of agrihoods for improving health, with an emphasis on integration of community engagement. Study design: This narrative review followed Green and Colleagues’ (2001) “best-evidence synthesis” approach and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist. Methods: A robust search strategy was applied across the PubMed, Embase, Scopus, Science Direct, ProQuest, and Google Scholar databases. All searches and screenings were conducted manually using the primary key term “agrihood/s” and several secondary terms. Eligible peer-reviewed journal articles, reports, and academic theses published until November 2024 were included. Results: We extracted and analyzed 29 sources and organized our findings into four key themes: (1) Opportunities for improved health and wellbeing; (2) Challenges to promoting equal and equitable health; (3) Community-engagement for helping to meet health-related needs; and (4) Recommendations to enhance future development. Within these, fifteen sub-themes are identified and discussed in further detail. Conclusions: This synthesis adds to the scientific knowledge base and can help inform future agrihood initiatives led by researchers, organizations, and developers. We anticipate that the literature on agrihoods will continue to expand as more research is conducted, warranting a future scoping or systematic review.

Background:Access to greenspace supports mental health, but most studies focus on the presence of greenness rather than actual use. Fewer explore how the association may vary within city boundaries and suburban areas. Objective:We examined associations between neighborhood-level greenspace visits and poor mental health across nine U.S. metropolitan statistical areas (MSA), adjusting for Normalized Difference Vegetation Index (NDVI), demographics, and social vulnerability, and evaluated spatial heterogeneity. Methods:We integrated greenspace visits, CDC PLACES mental health estimates (2023), Social Vulnerability Index (2018), demographics (ACS 2010-2014), and NDVI (2021). Ordinary least squares (OLS) models were conducted for each metro and overall, adjusting for NDVI, SVI themes, and demographics. Multi-scale geographically weighted regression (MGWR) assessed spatial variation. Results:The sample included 13,152 tracts across nine MSAs (72.5 million residents). Poor mental health prevalence ranged from 12.9% (DC) to 18.7% (Houston), while visits ranged from 11.5 (Houston) to 33.2 (DC). In pooled models, more visits indicated better mental health (β = -0.029; R 2 = 0.62). Metro-specific models showed strongest effects in Houston (β = -0.113; R 2 = 0.716) and Atlanta (β = -0.096; R 2 = 0.634), with weaker results in Philadelphia and DC. MGWR revealed strong urban-core associations in Houston, Atlanta, and Dallas, while peripheral tracts often showed null effects. Conclusions:Greenspace engagement, not just presence was linked to lower poor mental health across the metros, though associations varied by neighborhood. Promoting use may improve mental health, but interventions should account for local context and social vulnerability.

Abstract Background Rural United States communities often experience disproportionate burdens of obesity, cardiovascular disease, diabetes, and premature mortality. Built environment constraints, including limited sidewalks, recreation facilities, and access to nutritious foods, may restrict opportunities for adoption and maintenance of healthy eating and physical activity behaviors. Civic engagement approaches empower residents to assess community needs, develop action plans, and implement policy, systems, and environmental (PSE) strategies. However, few randomized trials have examined implementation of PSE strategies and their impacts in rural adult populations. This study evaluated implementation of Cooperative Extension-led Change Club (CC) community project action plans aimed at facilitating PSE change in six rural and micropolitan Texas and New York intervention communities. Presently, we document implementation outcomes and identify factors that may have influenced implementation using the Consolidated Framework for Implementation Research (CFIR). Methods CCs followed a 24-module curriculum facilitated by trained Extension educators. Approved action plans were provided with seed money to target diet and physical activity PSE changes. Implementation outcomes regarding the action plans were tracked through educator reports, interviews, and proposals. CFIR factors were assessed during the early stages of action plan implementation using interviews with educators and participant residents. Results All six intervention communities implemented action plans, most of which had multiple components. Each prioritized environmental changes and most focused on addressing physical activity. Implementation timing and continuity varied, influenced by external factors such as weather and local approvals. CFIR analysis identified beliefs about feasibility, stakeholder engagement, and group decision-making as key factors influencing implementation. Conclusions Rural CCs successfully launched a variety of built environment initiatives. This implementation evaluation highlights pathways and barriers related to scaling rural civic engagement strategies. Trial registration Clinical Trial #NCT05002660 (August 2021).

Introduction:Obesity and related chronic diseases in the U.S., particularly within rural communities and/or medically underserved areas, are a major societal and cost burden. Built environments with health-promoting attributes, which can be influenced through civic engagement, are a potential pathway to help address this substantial problem. Methods:We conducted a community-randomized delayed intervention trial in medically underserved rural communities (n = 12) in Texas and New York to evaluate the impacts of a civic engagement curriculum designed to create healthier physical activity and nutrition environments, called the Change Club, on individual measures of chronic disease risk and related behaviors and on collective and environmental outcomes 2 years after baseline. Residents within each community were recruited and enrolled to help lead community change activities; they are referred to as Change Club Members. Results:Using an intent-to-treat framework, no net effects were observed when comparing year-2 individual and collective outcomes for the intervention arm relative to the control arm, adjusting for baseline outcome values. Exploratory analyses compared attendees (61%) to non-attendees (39%) in the intervention group and found attendees had higher year-2 values than non-attendees (with baseline adjustment) on the primary outcome and two other individual measures: Life's Simple 7 composite cardiovascular risk score (+0.93, p = 0.006), World Cancer Research Fund/American Institute for Cancer Research composite cancer risk score (+0.54, p = 0.008), and healthy eating motivation (+0.27, p = 0.028). Discussion:This is among the first studies to evaluate how a civic engagement curriculum targeting built environment change may impact the health of residents who actively attend the Change Club meetings. While net impacts on the whole sample were not observed, exploratory analysis indicated that the approach holds promise when participants attend. Clinical trial registration:http://www.clinicaltrials.gov, identifier (NCT05002660).

OBJECTIVE:Transportation noise is increasingly recognized as a cardiometabolic stressor, but its relationship with type 2 diabetes mellitus (T2DM) remains poorly defined. We examined whether transportation noise exposure was associated with incident T2DM in a large, diverse U.S. healthcare system cohort. METHODS:We identified adults without baseline T2DM from the Houston Methodist Learning Health System Registry (2016-2023). Transportation noise exposure was assigned at the census block group level using the 2020 U.S. Department of Transportation National Transportation Noise Map. Five noise categories were examined: Road, Rail, Aviation, Road plus Aviation and Total. Cox proportional hazards models estimated associations across predefined categories, Quiet (≤45 dB), Moderate (45-54 dB) and Loud (≥55 dB), and per 10 dB increase, adjusting for demographics, cardiometabolic risk factors, socioeconomic vulnerability and PM₂.₅. RESULTS:Among 984 658 adults (2.1 million person-years), 39 587 developed T2DM (1.88 per 100 person-years). Loud rail noise (HR 1.14; 95% CI: 1.01-1.29) and loud total noise (HR 1.17; 95% CI: 1.03-1.33) were associated with higher T2DM risk. Continuous models showed similar patterns, with each 10 dB increase in rail noise (HR 1.09; 95% CI: 1.05-1.13) and road noise (HR 1.04; 95% CI: 1.01-1.08) associated with a higher hazard of incident T2DM. Effect sizes were modest but internally consistent and aligned with prior environmental noise studies. CONCLUSION:Transportation noise, particularly rail noise, was associated with higher T2DM risk. Given plausible mechanisms involving sleep disruption and stress-related neuroendocrine activation, these findings add to evidence linking environmental noise to metabolic health and motivate further studies to evaluate causality and potential benefits of noise mitigation.

Urbanization and increased screen time among young adults have contributed to reduced time spent in nature, limiting access to its associated health benefits. Virtual reality (VR) offers a promising solution by simulating nature exposure in controlled environments and may serve as a short-term alternative for individuals with limited access to natural environments. This pilot randomized controlled trial examined the effects of a 10-min walk in a computer-generated urban VR environment featuring either high or low levels of greenness on physiological stress markers, measured through skin conductance levels and blood pressure, and psychological well-being, assessed via self-reported surveys. Of the 134 participants recruited, 131 provided complete survey data, and 121 had complete skin conductance data. No significant between-group differences in physiological or psychological outcomes were found after adjusting for VR presence. However, higher levels of perceived presence were significantly associated with greater subjective vitality and lower post-VR energy levels. Skin conductance levels significantly changed over time within groups but did not differ significantly between groups. Both groups experienced increased fatigue and decreased vitality following VR exposure, though the high-greenness group demonstrated comparatively smaller declines in vitality and slight physiological improvements. These findings suggest that higher levels of virtual greenness may provide modest psychological and physiological benefits by buffering against urban stressors. However, increased fatigue highlights a potential trade-off of immersive VR. Future VR interventions should aim to optimize the balance between immersion and sensory input to maximize health benefits while minimizing discomfort.

Purpose To assess changes in publications of health behavior research in leading journals across a 20-years period.Design Systematic comparative descriptive snapshot analysis of all primary research-based articles published in the 2003 and 2023 issues of five leading health behavior journals.Setting Document review.Sample Articles (n = 1207) published in the following journals in 2003 and 2023: American Journal of Health Promotion, American Journal of Preventive Medicine, Annals of Behavioral Medicine, Health Education & Behavior, and Health Psychology.Analysis T-tests and chi-squared tests were used to assess differences in publication characteristics between the 2 years.Results The number of published studies more than doubled between the two time points. Significant changes were seen between the health behavior of interest, methodology, setting, and the use of large data sets.Conclusions Compared to 2003, there were twice as many articles published in 2023. Sample sizes were larger, but cross-sectional studies still predominated. Theoretical frameworks have greatly expanded, and there were no clear preferred theories.Critical Limitations Papers were only abstracted from five journals across 2 years. Comparisons of other journals and other volumes may yield different results.

Growing evidence links nature contact to improved physical and mental health, yet self-reported measures often rely on undefined concepts of “time in nature.” While experts define nature spaces broadly, from national parks to houseplants, it is unclear if the public shares this view. This study examined how adults perceive the “nature richness” of various environments to determine which spaces the public considers valid for nature contact. A stratified panel sample of U.S. adults ( N = 303) completed an online survey rating 16 specific places on a scale from 0 (absolutely zero nature contact) to 100 (complete nature experience). Places were categorized into three subscales: Open Nature (e.g., national parks, lakes), Integrated Nature (e.g., yards, neighborhoods), and Mediated Nature (e.g., VR, screens). Participants held a hierarchical view of nature. Only five of the 16 items received median ratings above 50/100, with Open Nature destinations rated significantly higher than Integrated Nature spaces found in daily life. Mediated Nature was rated lowest overall; however, Black participants rated Mediated Nature significantly higher than all other racial/ethnic groups. Nature connectedness positively predicted ratings across all categories. Results reveal a disconnect between expert and public definitions of nature. By largely discounting Integrated Nature (backyards, neighborhoods), the public may under-report nature contact in standard health surveys. Furthermore, the higher endorsement of Mediated Nature among Black participants may reflect structural inequities in access to safe outdoor green spaces (the “Nature Gap”). Future surveillance tools should differentiate between “time outdoors” and “time in nature” to accurately capture health-promoting exposure.

PurposeTo examine multiple implementations of the Change Club (CC) curriculum.ApproachCompiled information about studies that used the CC curriculum.SettingTen research studies using the CC curriculum.InterventionCivic engagement policy, systems, and environmental change (PSE) curriculum, in which small groups follow a stepwise process to change physical activity- and/or food-related aspects of their community.MethodReviewed study records to describe multiple implementations of the CC curriculum.ResultsThe studies varied in terms of U.S. region, inclusion criteria, number of CC members, duration, and outcomes measured. Curriculum implementation varied, with session lengths varying from 30 minutes to multiple hours. Some studies included other interventions such as walking clubs. Across the 10 studies, there were 62 CCs, with seed monies ranging from $600 to $5000. The majority of CCs were facilitated by a USDA Cooperative Extension agent; 95% of CCs successfully completed a PSE project. Sixty-one percent of projects included physical activity elements only.ConclusionKey recommendations include the importance of involving stakeholders, encouraging positive CC group dynamics, ensuring CC members understand the time and effort of PSE projects, identifying and cultivating facilitators that have capacity and can transition the project to group members, completing CC modules in a short period of time to retain members, and including group members who have existing community connections.Clinical Trial #sNCT05002660, NCT05677906, NCT05867433.

Nature prescriptions (NRx) can help address mental health issues, wellness, physical inactivity, and lack of time spent outdoors but have yet to become widespread in clinical practice. This study explores the behaviors and characteristics of health care providers (HCPs) who issue NRx; motivators and barriers to issuing them; health conditions for which HCPs issue NRx; the time it takes to issue a prescription; the satisfaction level; and perceptions of their effectiveness. A cross-sectional study of an online survey was conducted on 135 HCPs who had registered with ParkRxAmerica.org (aka Natureprescribed.org; PRA). We assessed prescribing behaviors, connectedness to nature (CNS), time spent in nature, burnout, motivators and barriers to and reasons for prescribing, and demographic variables with chi-square test, t-test, and analyses of variance. Half (56%) of respondents issued NRx. This group reported greater CNS and more frequent outdoor breaks. Within this group, frequency of issuing prescriptions, CNS, park visits, outdoor breaks, and less screen time were positively correlated (p < 0.01). Most prescriptions were written for mental and general health conditions, and physical inactivity. More than 80% thought prescriptions were effective for improving physical and mental health. Several barriers to issuing prescriptions existed. HCPs who wrote more prescriptions reported feeling greater CNS, visited greenspace and nature more frequently, took more frequent workday breaks, and reported less screen time. This emphasizes the importance of frequent exposure to nature, both during and outside of work, to improve NRx writing.

Virtual reality (VR) can provide access to restorative environments and sensory stimulation for individuals in isolated, confined, and extreme environments. We developed a nature-based VR intervention featuring three scenes (Garden, Forest, Beach) and examined the effects of multisensory augmentation with location-based olfactory, wind, and thermal stimuli (VR + OWT). Over a two-week period, fifty-one participants were assigned to a no-intervention control, standard audiovisual VR, or augmented VR (VR + OWT) condition. Data collection included weekly assessments of affect, stress, and cognitive performance; post-VR measures of affect, presence, and perceived restorativeness; and open-ended feedback. Both VR and VR + OWT groups produced immediate and sustained reductions in negative affect with no sustained systematic benefits on cognitive performance. The addition of olfactory, wind, and thermal stimuli enhanced presence for some scenes; however, feedback indicated that sensory mismatches and stimulus intensity occasionally detracted from the experience and may have contributed to lower coherence ratings in the VR + OWT group. In contrast, the perceived restorativeness of the VR environment was driven primarily by scene content (Garden vs Forest vs Beach) rather than the level of sensory stimulation. These findings support the potential of virtual nature to promote well-being and underscore the importance of coherence across sensory modalities for multisensory augmentation.

Rural populations have worse health outcomes than urban populations. Community-based health interventions can help to improve these outcomes, but rural populations are underrepresented in research. The goals of the study were to describe and examine the effectiveness and cost-effectiveness of strategies to recruit into a rural, community-based health intervention study. The Change Club study is a community-based health intervention conducted in medically underserved rural communities in Texas and New York to assess whether a civic engagement program improves health among intervention participants and their communities. The study was promoted online, via mailings, email, educators, flyers/posters, and traditional media, and encouraged referrals from friends and family members. For each recruitment strategy, the resulting number of enrolled participants and costs were compiled. The most effective recruitment strategy was letters, which contributed 37.7

Background Green space has been linked with cardiovascular (CV) health. Nature access and quality may have significant impact on CV risk factors and health. Objectives The authors aimed to investigate the relationship between NatureScore, a composite score for natural environment exposure and quality of green spaces, with CV risk factors and atherosclerotic cardiovascular diseases (ASCVD). Methods A cross-sectional study including one million adult patients from the Houston Methodist Learning Health System Outpatient Registry (2016-2022). NatureScore is a composite measure of natural environment exposure and quality (0-100) calculated for each patient based on residential address. NatureScores was divided into 4 categories: nature deficient/light (0-39), nature adequate (40-59), nature rich (60-79), and nature utopia (80-100). CV risk factors included hypertension, diabetes, dyslipidemia, and obesity. Results Among 1.07 million included patients (mean age 52 years, female 59%, Hispanic 16%, Non-Hispanic Black 14%), median NatureScore was 69.4. After adjusting for neighborhood walkability, patients living in highest NatureScore neighborhoods had lower prevalence of CV risk factors (OR: 0.91, 95% CI: 0.90-0.93) and ASCVD (OR: 0.96, 95% CI: 0.93-0.98) than those in lowest NatureScore neighborhoods. A significant interaction existed between NatureScore and Walkability (P < 0.001), where those in high NatureScore (≥60) high walkability (≥40) areas had lower prevalence of CV risk factors (OR: 0.93, 95% CI: 0.90-0.97, P < 0.001) and were more likely to have optimal CV risk profile (relative risk ratio: 1.09, 95% CI: 1.04-1.14, P = 0.001). Conclusions These findings suggest that while green spaces benefit health, their accessibility through walkable environments is crucial for cardiovascular disease protection.

Background Throughout rural and urban communities in the United States, as well as in many places globally, chronic disease rates are high and increasing. Previous evidence suggests that residential environments and their designs play a role in shaping health behaviors and outcomes. Combining land use development with urban agricultural practices to create agriculturally-integrated neighborhoods (‘agrihoods’) has potential for improving the built, natural, and food environments while building community. However, the research on agrihoods is limited, and no structured reviews to date have synthesized the literature pertaining to agrihood impacts on community health. We begin filling this gap by providing a narrative review of the published and grey literature exploring opportunities and challenges of agrihoods for improving health, with an emphasis on integration of community engagement. Study Design This narrative review followed Green and Colleagues’ (2001) “best-evidence synthesis” approach and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist. Methods A robust search strategy was applied across the PubMed, Embase, Scopus, Science Direct, ProQuest, and Google Scholar databases. All searches and screenings were conducted manually using the primary key term “agrihood/s” and several secondary terms. Eligible peer-reviewed journal articles, reports, and academic theses published until November 2024 were included. Results We extracted and analyzed 29 sources and organized our findings into four key themes: (1) Opportunities for improved health and wellbeing; (2) Challenges to promoting equal and equitable health; (3) Community-engagement for helping to meet health-related needs; and (4) Recommendations to enhance future development. Within these, fifteen sub-themes are identified and discussed in further detail. Conclusions This synthesis adds to the scientific knowledge base and can help inform future agrihood initiatives led by researchers, organizations, and developers. We anticipate that the literature on agrihoods will continue to expand as more research is conducted, warranting a future scoping or systematic review.

Context: Individuals who walk regularly are more likely to meet recommended physical activity guidelines than non-walkers; however, rural US adults walk less than urban adults. The built and social environment, perceived walkability and walking are bidirectionally related with each other. Objective: This study’s purpose was to assess the associations of physical activity-related social norms and frequency of walking in the neighborhood with perceived walkability among rural adults. Study Design & Main Outcomes: The data for this cross-sectional analysis comes from a randomized trial with 18 rural Oregon libraries. As part of baseline assessment, participants completed surveys on physical activity-related social norms, perceived walkability, frequency of walking in the neighborhood, and demographic items. We assessed bivariate correlations and ran linear regression models with perceived walkability as the outcome and social norms (social environment) and frequency of walking in the neighborhood (built environment experience) as predictors with covariates of age, gender and income. Setting and Participants: Adult residents of 18 rural communities in Oregon. Results: Of the 313 participants who completed the survey, 60% were 65 and older, 92% white and 86% women; 17% reported walking in the neighborhood less than once a month and 5% reported walking 5 or more days/week. We found positive correlations between perceived walkability and frequency of walking in the neighborhood ( r = .23, p < .01), and social norms ( r = .47, p < .01). The linear regression model explained 28% of the variance in perceived walkability (adj r -squared = 0.26). Social norms (unstandardized coefficient = 0.37, 95% CI: 0.28,0.46) and frequency of walking in the neighborhood, (unstandardized coefficient = 0.06, 95% CI: 0.02, 0.10) were positively associated with perceived walkability. Conclusions: Among a group of rural adults social norms had a greater influence on perceived walkability than frequency of walking in the neighborhood. Intervening in the social environment could impact perceived walkability and ultimately walking among rural adults.

Objective Assess relationships between diet quality and healthy eating motivation, confidence, social support, and food environment. Methods The study sample of a community-randomized controlled intervention trial responded at baseline to sociodemographic, diet, diet-related psychosocial factor (motivation, confidence, social support), and environment (healthy food availability, food shopping motivation) questions. Linear regression was used to analyze cross-sectional associations between dietary intake (diet quality, fruit and vegetable, fiber, ultraprocessed food) and psychosocial and environmental factors. Results Data from 2420 rural adults were analyzed. Psychosocial factors were positively associated with fruit and vegetable and fiber consumption and diet quality. Psychosocial factors were negatively associated with ultraprocessed food consumption frequency, except for social support from friends. Fruit and vegetable availability was positively associated with fruit and vegetable and fiber consumption and overall diet quality. Food shopping motivation was positively associated with fruit and vegetable intake and overall diet quality. Conclusions and Implications These findings contribute insights into ways psychosocial and environmental factors influence diet quality within rural studies.

BackgroundPoor nutrition and inadequate physical activity are key contributors to rising chronic disease rates across the United States. It is well-documented that neighborhood built environments play an important role in shaping these modifiable health behaviors. Agriculturally-integrated neighborhoods (“agrihoods”) offer a relatively new and promising approach to health-promoting residential design and development. Centered around a working farm, agrihoods are designed to connect residents with fresh foods and outdoor spaces that encourage physical activity. However, no rigorous or longitudinal evaluations of their impact on resident health have been conducted to date. We detail the protocol for a naturalistic study that aims to (1) assess short-term changes in dietary intake, physical activity, cardiometabolic health indicators, and social connectedness among agrihood and matched comparison residents; (2) document time use with and preferences for agrihood design features; and (3) examine agrihood economic benefits.MethodsThis mixed-methods, quasi-experimental study will last approximately 6 months including assessment at three timepoints (baseline, 3 months, 6 months). Agrihood participants will be new adult residents in an agrihood residential development (Richmond, TX), while comparison participants will be adults currently residing in a nearby residential development (Katy, TX). All participants will complete three 30-min online surveys, including items to produce geospatial data; agrihood participants will complete two additional 30-min in-person health assessments and three timepoints of accelerometer wear on 7 consecutive days, with a subsample completing three 30-min online dietary recalls. Data will be collected by trained staff, and Difference-in-Differences (DiD) generalized linear mixed-effects models will examine longitudinal change and its interaction with participant groups. The economic analysis will account for break-even time, farmer compensation, maintenance costs, and public incentive programs.DiscussionThis will be the first study to examine a longitudinal cohort of new agrihood residents compared to a master planned residential development to understand the use and health impacts of agrihood living. Our data-driven design, including biological data collection, device-captured physical activity, and validated self-report measures, can pave the way for future research, policy and philanthropic initiatives to adapt and scale models for developments that promote environmental and economic growth, and improve human health and wellbeing.Clinical trial registrationhttps://clinicaltrials.gov/study/NCT06950775, Identifier NCT06950775.

Background: Access to and use of green spaces are increasingly recognized as vital for cardiovascular health, yet few studies have quantified green space exposure behaviorally or explored how climate might modify its effects. Methods: Using population mobility data, we estimated annual green space visits per person at the census tract level to examine the association between green space use and coronary heart disease (CHD) prevalence. We focused on three U.S. metropolitan areas with distinct climates: Houston (hot), Minneapolis (cold), and San Diego (mild), to assess whether the relationship between green space use and CHD varies by climate. Annual green space visit counts in 2021 were calculated per person using Advan Patterns mobility dataset (formerly SafeGraph Patterns) and linked to 2021 CHD prevalence estimates from CDC PLACES at the census tract level. We conducted Pearson correlation analyses separately by metro area and further applied geographically weighted regression (GWR) models adjusting for socioeconomic vulnerability (CDC Social Vulnerability Index) to assess spatial heterogeneity in the association within each metro. Results: Houston had the lowest green space visitation rates, while Minneapolis had the highest ( Figure 1 ). Across all three cities, higher green space visits were associated with lower CHD prevalence (Houston: r = –0.32; San Diego: r = –0.25; Minneapolis: r = –0.22; all p < 0.001). Notably, the association was strongest in Houston despite its lowest visit rate, suggesting that barriers like low availability of green space or extreme heat may limit usage, but for those who do access green spaces, the cardiovascular benefit is substantial. GWR revealed spatial variation in effect strength, with suburban areas consistently showing stronger protective associations than urban cores ( Figure 2 ). This rural-urban gradient was most pronounced in Houston, highlighting potential inequities in green space access and its health benefits under extreme climatic conditions. Conclusion: Behavioral exposure to green space is inversely associated with CHD prevalence across diverse climates. The stronger protective association observed in Houston underscores the potential amplified benefits of green space in environments where access may be constrained. These findings suggest targeted urban planning and climate adaptation strategies could enhance cardiovascular outcomes, particularly in heat-prone, under-visited areas.

BACKGROUND:Psychosocial and built environment (BE) factors can influence physical activity (PA). Objectives were to assess whether psychosocial or BE variables were associated with PA and whether associations differed by sociodemographic characteristics in rural communities. METHODS:The sample included 2215 adults enrolled in a healthy lifestyle intervention cluster-randomized trial. Sociodemographic variables included age, sex, race/ethnicity, education, and income. Health variables included general health status and body mass index. PA was assessed using the International Physical Activity Questionnaire-long form. Metabolic Equivalent-minutes per week were calculated for total PA, moderate and vigorous PA, and walking. Psychosocial (exercise attitudes, exercise confidence, social support for PA from family/friends) and BE variables (walking environment, sidewalks, street shoulders, community safety, community aesthetic quality) were assessed via questionnaire. Linear regressions modeled bivariate associations between PA and PA context variables. Multivariate regression models evaluated whether sociodemographic or health variables modified relationships between PA and PA context variables. RESULTS:All psychosocial measures were positively associated with all measures of PA. Walking environment and community safety were the only BE measures associated with all measures of PA. Being an older adult (65+) had significantly greater effects on exercise attitudes, exercise confidence, and social support from friends on walking. Education and income did not consistently moderate associations between psychosocial factors and any measure of PA. CONCLUSIONS:Future studies should confirm whether psychosocial characteristics are associated with PA in other populations and explore how these effects are moderated by sociodemographic characteristics. Further research is needed on the role of the environment in influencing PA in rural communities.

Purpose-Motivated by the psychoevolutionary theory, this study investigated the impact of a biophilic environment in hospital rooms presented in virtual reality (VR) to simulated patients on perceived healing. It explored how varying degrees of nature exposure through window views, indoor plants and green-themed d & eacute;cor, influenced patients' recovery perceptions, offering insights into evidence-based healthcare design. Design/methodology/approach-A total of 12 VR scenarios of a hospital room were created, manipulating biophilic design elements. Participants rated the extent to which each scenario was perceived to contribute to the ability to heal after undergoing a hospital patient transportation narrative and acute external stressor process. The ratings were analyzed using full-profile conjoint and group conjoint analyses. Findings-The results demonstrated that views of dense green nature from the window, abundant indoor plants and green colored room d & eacute;cor had the highest utility scores among attributes influencing the room's perceived contribution to healing. In contrast, views of adjacent buildings and the hospital building envelope were negatively associated with perceived healing. Research limitations/implications-Higher saturation of a green environment and interior design in hospitals, including views of nature from windows, higher quantities of indoor plants and prevalence of green-colored d & eacute;cor, can potentially boost patients' healing confidence and psychological recovery, supporting their overall therapeutic experience. Originality/value-This study explores simulated patients' perceptions of hospital room environments in VR, focusing on biophilic and verdant environments. It examines views of nature, buildings and the sky through windows, presence of plants and interior design features including green walls.